Mental health homicide investigation legacy report into the care and treatment of Ms X

All teams have undertaken team based training on care planning, including collaboration with the service user and involvement of relatives. Each individual practitioner’s approach to collaborative working is reviewed through regular caseload supervision processes, using an agreed profiling tool and monitored through line management route. The Trust has introduced a monthly audit of caseload records, which includes evidence that a holistic care plan is in place and that the care plan has been shared with the service user and where appropriate their carer. The Trust has developed further best practice guidance on assessment, formulation and care planning and has launched this as part of a Clinical Toolkit. The toolkit is available to all staff via the Trust intranet. The Clinical Toolkit strongly emphasises service user and carer involvement in all aspects of assessment and care planning. Through the Information for Quality system all teams are required to self-assess themselves against the Care Quality Commission Outcomes on a monthly basis. This includes reviewing health and social care records to ensure, where appropriate, care plans have been shared with service users. All teams are also required to audit core standards for record keeping on a monthly basis in randomly selected service user records. This audit includes evidence that assessments and their outcomes are shared with service users and carers and that their understanding of the assessment is recorded. Further audit of the record requires evidence that the care plan clearly outlines the service users’ needs and what specific interventions will be provided to support them.

Use of medication is included within a service user’s care plan, and any risk factors associated with this, including non-concordance, are addressed through the risk management within this, including a crisis and contingency plan. The monthly audit tool assesses whether Care Plans are in place to address the needs identified in the risk assessment and core assessment and that they outline clear actions and interventions, including who is responsible, to specifically address the identified needs.

Guidance on the prescribing of antipsychotics is included in the Trust Rapid Tranquillisation policy, in the AWP medicine formulary. Guidance and alerts are published on the AWP external pages and this is available to all internal and external prescribers. The e-learning packages for medicines have been revised and include prescribing of antipsychotics. Medicine management is mandatory for all prescribers and nursing staff. A medicine information service has also been established and is available to provide advice to prescribes on individual patients and out hours there is an on call pharmacist who can also provide advice on medicines and prescribing. The Trust now undertakes more systematic audits and reviews of prescribing practice linked to The Prescribing Observatory for Mental Health (POMH-UK).

The Social Care Pathways Lead for the Trust has reviewed local S117 procedural documentation and is working with Social Care Leads from the 6 Local authority areas to update this documentation and to develop a common protocol on management and discharge from S117, including the recording and management of S117 data. There are also on-going discussion with CCG’s on their role in relation to S117 in particular following recent DH guidance on S117 following the changes set out in the Health and Social Care Act 2012. S117 and the review/update of S117 agreements and practice (including relevant new case law) are also regularly considered at the joint meeting between social care leads and the Trust An audit of section 117 discharge planning has been completed and has identified changes that need to be made at a systems level, an administrative level and a practice level. These actions will produce more robust systems that will lead to more effective engagement with section 117 processes by AWP and its Local Authority partners.

As part of individual supervision (including in EI), team managers and senior practitioners are scrutinising a number of patient records, using an agreed caseload management template to audit caseloads and interventions. This includes risk assessment and risk management plans. Outcomes are recorded as part of the supervision record including any actions required. The Trust introduced a monthly audit of caseload records in April 2013, which audits against 10 questions aligned to the use of the Care Programme Approach being adhered to in practice. This process has been further reviewed, with the audit tool and guidance updated in April 2014. The Trusts revised supervision policy sets the standard that caseload management supervision occurs monthly and includes team managers and senior practitioners scrutinising the size and complexity of caseloads and assuring that all aspects of CPA, risk management and safeguarding are appropriately implemented and recorded. Team supervision is monitored through the Trust Information for Quality system. The Trust audits the quality of each team’s record keeping standards using the Information for Quality System. Further revisions to the CPA and Risk Policy include the requirement for all service users to have a Crisis, Relapse and Contingency Plan in place outlining individuals relapse indictors and the action that both the service user and carer(s), and the service will take in event of a crisis or relapse. The Crisis, Relapse and Contingency Plan is shared with the GP and others involved in the individual’s care and includes a telephone number to call in a crisis. As part of the Trust Information for Quality system audit of randomly selected records for each team, the presence of a Crisis, Relapse and Contingency plan is one of the standards reviewed.

New Safeguarding procedures are in place in Bristol through joint working arrangements between mental health services and local authority partners. AWP has led the development of the Bristol Safeguarding Adult multi-agency policy, including providing clearer guidance to practitioners on the thresholds for making safeguarding adult alerts to the local authority. The Trust has been involved in the development of safeguarding adult policies and procedures in all areas of the Trust. It has participated in the development of performance reporting frameworks in Bristol, and has participated in the work to develop safeguarding adults practice in Bristol, including providing evidence to Council scrutiny committee in 2013 for its subsequent report on adult safeguarding on AWP practice and safeguarding training provision. The Trust has agreed safeguarding standards in its NHS Core Contract, and reports on these as required, and annually through its annual safeguarding report. It reviews these standards annually with commissioners to ensure that they demonstrate effective safeguarding practice The Level 1&2 training has been further developed, and a new enhanced training was introduced from December 2012 for practitioners. The south west thresholds framework (and where relevant local thresholds guidance) issued in 2010/2011 has been incorporated into Trust policy and training, and are available to all practitioners on dedicated Safeguarding pages on the Trust intranet. Safeguarding training requirements have been reviewed and increased, with a requirement for all staff to have completed Level 1&2 safeguarding training, and Level 3 safeguarding children training being required for all registered professionals working in the community, and senior staff working within inpatient services. Compliance levels of 90% of the target staff groups have been applied to both courses and achieved within Bristol. The number of alerts made by AWP staff has risen significantly since 2009, and alert rates are monitored and reported as part of AWP’s internal governance and performance arrangements, as well through the relevant safeguarding adult Boards. Access to safeguarding information and training resources are available to all practitioners through the Trust dedicated safeguarding pages on the Trust intranet, which are available on a local specific basis (e.g. “safeguarding in Bristol” pages).